MEDICARE: SQUARE CARE MEDICAL GROUP, LLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician
2	207VM0101X	Maternal & Fetal Medicine Physician
3	207V00000X	Obstetrics & Gynecology Physician	135297	NY

General Provider Information

NPI Number	:	1457392763
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SQUARE CARE MEDICAL GROUP, LLP

Provider Business Mailing Address
First Line	:	900 MERCHANTS CONCOURSE STE 216
Second Line	:
City	:	WESTBURY
State	:	NY
Zip	:	11590-5114
Country	:	US
Telephone Number	:	516-758-2556
Fax Number	:

Provider Business Practice Location Address
First Line	:	40 CROSSWAYS PARK DR
Second Line	:
City	:	WOODBURY
State	:	NY
Zip	:	11797-2036
Country	:	US
Telephone Number	:	516-496-3900
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. HENRY K PRINCE
Credential	:	M.D.
Telephone Number	:	516-496-3900

Provider Enumeration Date	:	06/09/2006
Last Update Date	:	03/19/2019

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